Delirium Tremens, Alcohol Use Disorder in MHN

MHN

1. Delirium Tremens It is the most severe alcohol withdrawal syndrome. It usually occurs within 2 to 4 days of completer or significant abstinence from heavy alcohol drinking in about 5% of patients, as compared to acute tremulousness which occurs in about 34% of patients Its course is short, with recovery occurring within 3 to 7 days Death can occur in 5-10% of patients with delirium tremens and is often due to cardio-vascular collapse, infection, hyperthermia or self-inflicted injury

2. Characteristics Clouding of consciousness with disorientation in time and place Poor attention span and distraction Visual hallucinations and illusions which are often vivid and very frightening; tactile hallucinations of insects crawling over the body may occur Dehydration with electrolyte imbalance

3. Cont’d… Sympathetic overdrive (autonomic hyperactivity) causing marked autonomic disturbance with tachycardia and hypertension causing cardiovascular collapse, fever, sweating, and pupillary dilation Psychomotor agitation and ataxia Insomnia with a reversal of sleep wake pattern

4. Risk factors Previous history of delirium tremens Previous history of alcohol withdrawal seizures Co-existing infection or medical problems including pancreatitis or hepatitis Recent higher-than-normal levels of alcohol intake. Older age Abnormal liver function More severe withdrawal symptoms on presentation

5. Treatments for delirium tremens This should be in a hospital setting. Intensive care may be needed for very unwell patients. It should first include assessment and management of 'Airway, Breathing and Circulation (ABC)' . Any hypoglycaemia should be treated.

6. Cont’d… 1. Supportive therapy: This important component of treatment of alcohol withdrawal syndrome and delirium tremens (DTs) includes providing a calm, quiet, well-lit environment; reassurance; ongoing reassessment; attention to fluid and electrolyte deficits; and treatment of any coexisting addictions

7. Cont’d… 2. Thiamine: Thiamine can be useful for preventing confusion, ataxia, ophthalmoplegia ( Wernicke encephalopathy ) and Wernicke-Korsakoff syndrome

8. Cont’d… 3. Magnesium: Alcoholic individuals frequently have large total body deficits of magnesium, and symptoms and signs of magnesium deficiency include hyperactive reflexes, weakness, tremor, refractory hypokalemia, reversible hypoparathyroidism with hypocalcemia, and cardiac dysrhythmias

9. Cont’d… 4. Benzodiazepines: Based on the Riker Sedation Agitation Scale (RSAS) or the Richmond Agitation Sedation Scale (RASS), very-high-dose bolus therapy, with addition of phenobarbital as needed, may help reduce the need for mechanical ventilation and the length of time in the ICU